Template

Medical Observation Template

by malcolm whyte, from the Community

Use this medical observation template to support emergency and clinical care. Capture safety checks, vital signs, AVPU, oxygen saturation, pulse, blood pressure, temperature, blood glucose, pain scores, and notes. Document SAMPLE history, Glasgow Coma Scale, and a concise drugs formulary for common presentations such as anaphylaxis, asthma, chest pain, seizure, and hypoglycaemia. Record drugs administered, treatments provided, and clear handover details to ensure continuity of care.

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Digitize any process, procedure or policy

Eliminate mistakes made by paper-based processes

Create and share professional reports instantly

Confirm accountability and compliance with a digital log

With SafetyCulture you can

Digitize any process, procedure or policy

Eliminate mistakes made by paper-based processes

Create and share professional reports instantly

Confirm accountability and compliance with a digital log

About author

Community

This community page makes available free workplace checklists and templates created by other users within the SafetyCulture community. SafetyCulture has re-published this content and where possible, has credited the original author. SafetyCulture has not verified the accuracy, reliability or suitability of any community content. You agree that your use of any of this content is in accordance with SafetyCulture’s Terms and Conditions.

Template
A32 Medical Report Template
Use this A32 Medical Report template to document patient information and clinical assessments in a structured way. Capture personal details, mechanism of injury or illness, suspected symptoms, and vital signs including respiration, pulse, oxygen saturation, blood pressure, pupil size, blood sugar, and temperature. Record AVPU responsiveness, allergies, medications, past history, last oral intake, and events. Log treatment provided, evacuation needs, and maintain a daily patient timeline for ongoing care.
by Chief Officer, from the Community
Downloads: 0
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Template
NEWS Observations Checklist
Use this peer feedback checklist to guide systematic patient observations using the National Early Warning Score. Record pulse, respiratory rate and pattern, oxygen saturation and therapy, temperature, AVPU, and blood pressure. Calculate and document the EWS, interpret the score, set observation frequency, and escalate care when indicated. Ideal for training, revalidation, and quality improvement in clinical settings.
by Huon Snelgrove, from the Community
Downloads: 20+
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Template
Electronic Medical Record Documentation Audit
This Electronic Medical Record Documentation Audit template helps hospitals and clinics review the completeness and quality of clinical documentation across key areas of care. It covers consent validation, fall and pressure injury risk screening, pain assessment, social work and nutrition screening, patient and family education, timely medication administration, structured ISBAR handovers, nursing assessment and care planning, blood and blood product administration, discharge planning, and management of patient belongings. Use it to standardize audits, identify gaps, and strengthen compliance, documentation accuracy, and patient safety.
by Marnelli Ignacio, from the Community
Downloads: 30+
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Template
Clinical Coaching Checklist for Nursing Education
This clinical coaching checklist supports nursing education and preceptorship at the point of care. It guides mentors and new staff through competency verification and patient safety practices, including pain assessment, restraint documentation, medication safety, pressure injury prevention, fall risk assessment, IV site care, indwelling urinary catheter and CAUTI bundle, tracheostomy care, suctioning, EKG, PPE and swab collection, chest tube monitoring, vital signs, clinical alarms, blood transfusion, conscious sedation, high-alert drugs, VTE, patient identification, surgical checklists, CVAD insertion/maintenance/removal, and norepinephrine administration.
by Raf Collado, from the Community
Downloads: 10+
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A32 Medical Report Template

Use this A32 Medical Report template to document patient information and clinical assessments in a structured way. Capture personal details, mechanism of injury or illness, suspected symptoms, and vital signs including respiration, pulse, oxygen saturation, blood pressure, pupil size, blood sugar, and temperature. Record AVPU responsiveness, allergies, medications, past history, last oral intake, and events. Log treatment provided, evacuation needs, and maintain a daily patient timeline for ongoing care.

by Chief Officer, from the Community

Get

Template

NEWS Observations Checklist

Use this peer feedback checklist to guide systematic patient observations using the National Early Warning Score. Record pulse, respiratory rate and pattern, oxygen saturation and therapy, temperature, AVPU, and blood pressure. Calculate and document the EWS, interpret the score, set observation frequency, and escalate care when indicated. Ideal for training, revalidation, and quality improvement in clinical settings.

by Huon Snelgrove, from the Community

20+

Get

Template

Electronic Medical Record Documentation Audit

This Electronic Medical Record Documentation Audit template helps hospitals and clinics review the completeness and quality of clinical documentation across key areas of care. It covers consent validation, fall and pressure injury risk screening, pain assessment, social work and nutrition screening, patient and family education, timely medication administration, structured ISBAR handovers, nursing assessment and care planning, blood and blood product administration, discharge planning, and management of patient belongings. Use it to standardize audits, identify gaps, and strengthen compliance, documentation accuracy, and patient safety.

by Marnelli Ignacio, from the Community

30+

Get

Template

Clinical Coaching Checklist for Nursing Education

This clinical coaching checklist supports nursing education and preceptorship at the point of care. It guides mentors and new staff through competency verification and patient safety practices, including pain assessment, restraint documentation, medication safety, pressure injury prevention, fall risk assessment, IV site care, indwelling urinary catheter and CAUTI bundle, tracheostomy care, suctioning, EKG, PPE and swab collection, chest tube monitoring, vital signs, clinical alarms, blood transfusion, conscious sedation, high-alert drugs, VTE, patient identification, surgical checklists, CVAD insertion/maintenance/removal, and norepinephrine administration.

by Raf Collado, from the Community

10+

Get

Medical Observation Template

About author

You might also like

A32 Medical Report Template

NEWS Observations Checklist

Electronic Medical Record Documentation Audit

Clinical Coaching Checklist for Nursing Education

You might also like

A32 Medical Report Template

NEWS Observations Checklist

Electronic Medical Record Documentation Audit

Clinical Coaching Checklist for Nursing Education